“Lessons from Mayo Clinic” Author Talks About the Book’s Legacy

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Published:
March 14, 2018

Kent Seltman, retired director of marketing for the Mayo Clinic and co-author of the business classic Management Lessons from Mayo Clinic, travels around the world lecturing and consulting. The book, now in its 43rd printing in China, has been embraced by the Chinese ministry of health and is helping Chinese hospitals to become more patient-focused.

Question: You co-wrote a book, Management Lessons from Mayo Clinic: Inside One of the World’s Most Admired Service Organizations, that has become a business classic, based on your sixteen years of work as director of marketing for the Mayo Clinic. How did you come to write the book (along with Texas A&M University professor Leonard Berry)?

Answer: One of the things about working for the Mayo Clinic is that it creates opportunities that other institutions simply can’t provide. Because it is so well known as such an excellent healthcare provider, patients  — and scholars too — come from around the world to seek out answers from Mayo Clinic.

The book itself started with Leonard Berry, a very well-known and distinguished marketing professor at Texas A&M. He approached Mayo Clinic regarding the potential for a sabbatical research project in service delivery in healthcare.

Berry’s academic career focused on service-based businesses; first in financial services, then he moved on to hospitality services (particularly hotels and restaurants), and then the middle of his career was devoted to services related to retail. As he was moving to the final phase of his career, he wanted to focus on healthcare services. Mayo Clinic was his chosen place to start, and as director of marketing, his request came to me. I was in a position to obtain permission to give him access to all of our activities at the institution. This meant that Professor Berry and I worked closely together over that year.

He focused on service delivery to patients at Mayo Clinic as well as how different parts of the organization provided the administrative and support services that enabled the patient services to work remarkably well. Professor Berry’s findings were published in highly respected journals, including the Harvard Business Review. The leaders of Mayo Clinic were pleased and enlightened by his insights.

Ultimately, Berry was approached by a Mayo Clinic leader who encouraged him to write a book-length analysis of the management of Mayo Clinic. Berry then approached me with the idea of being the author, as he did not have time to write another book (he had published about 14 books already). I quickly declined the invitation, but then suggested that I would co-author with him. 

We shook hands, then began planning a book. And we completed it shortly before I retired from my career at Mayo at the end of 2008.

How did you write a book together, in practical terms? Who wrote what?

When we started the book we first sat down together for a day. We came up with an objective for the book: our goal was to provide ideas that all readers — not just in healthcare but any service business — could apply in their business operations. We didn’t feel that it would be possible for anyone to replicate Mayo Clinic, but there are dozens of policies, management processes, and cultural attributes that could help other organizations. We also wanted readers to understand how this institution had operated for 150 years at a premiere level without any major management crises or major shifts in its reputation, and how it was able to make adaptations to new medical knowledge and technology that had developed over the 15 decades of its history.

We outlined chapters based upon the major topics in the book. Then we each took five chapters. As we started thinking and writing we collapsed one of the chapters into another, so in the end I wrote five chapters, and Berry wrote four. We each had the responsibility of writing a first draft of our chapters. We emailed the draft to our co-author who would suggest changes — more or less content needed, rewrites of strained passages, and proofreading. This process ensured that the overall content would read as a single voice. When we had incorporated changes and were happy with the draft, we sent the content to a professional editor that we paid for ourselves. After that feedback there were more rewrites. Then we put each chapter to bed and started on the next chapter.

When the chapters were complete, we shared the manuscript with five senior leaders at Mayo Clinic. Our agreement with Mayo Clinic was that we as co-authors had unfettered control of the content — Mayo Clinic did not reserve a right to approve the content. We asked the five reviewers to read for accuracy of facts, names, and events described in the book. We did not want some error of fact to undermine the integrity of our analysis and conclusions on the larger topic of Mayo Clinic management.

When the manuscript was completed and we had received the suggestions from our five reviewers, we met for a week in Berry’s home in College Station, Texas to come up with the completed manuscript for submission to the publisher. We read each chapter carefully and did further rewrites to ensure the content was consistent throughout the book.

Was it more work than you anticipated? 

Oh, absolutely.

Would you do it again?

If I had the same topic, I would. I’m passionate about this message. I’d hope that every manager in healthcare would understand how Mayo Clinic operates. I know that many healthcare managers and clinicians dismiss Mayo Clinic as “Disneyland” or “Shangri La” — not the real world. But it is real.

Furthermore, Mayo Clinic’s management was a story waiting to be told. No book had comprehensively addressed Mayo Clinic’s management processes and guiding principles. Our subject was mystery for a lot of people, and there was a desire among many in healthcare to find out how it had succeeded so well for so long. We opened the door for people to look in. 

And is this what you attribute the book’s success to?

The name Mayo Clinic, which is arguably the most highly respected provider of healthcare services, caught the attention of potential readers. Furthermore, Leonard Berry’s name as an author brought instant credibility. He was one of the most published authors of academic services literature. His earlier books and journal articles created an instant audience of readers. Those two names accounted for early sales in bookstores and online. 

The longer-term sales seem to be based on the content of the book itself. Many Mayo Clinic employees have said that the book provided new insights to them. Also, the book is being used as a case study in a number of business schools. It seems that we wrote an accessible book that anyone could enjoy. We told a story that many wanted to hear. With a critical mass of readers, word-of-mouth recommendations then boosted sales.

My co-author says, “We collaborated on a book that is better than either of us could have written on our own. And in addition, we are still friends — in fact better friends — than before we wrote. That does not always happen with co-authors.”

Another contributor to the book’s success is the fact that it is based on solid research. Dr. Berry interviewed more than 1,000 patients and employees at Mayo Clinic. He observed patients and caregivers interacting in outpatient and inpatient settings. He observed surgeries and leadership committees. In the course of my career at Mayo, my team had completed hundreds and hundreds of research projects with patients, doctors, nurses, referring physicians, insurance companies, and the general public. But when I began to write I realized I needed a lot more specific information than the general outline I had structured. I had to do more interviews and seek more data, in order to come up with specific information that I thought was needed in my chapters.

How many copies have been sold so far?

We have sold over 400,000 so far. In terms of the category of management books it has been very successful. My co-author told me that around 6,000 business titles are published in English every year. The average lifetime sales for one of those books is around 2,500 copies. Lots of books are published, but relatively few have been blockbusters. Our book is not a “blockbuster,” but it is still much more successful that we could have imagined.

Also it is important to know that the majority of the sales have been in China, rather in the U.S. The English edition has sold around 100,000 copies, and continues to sell, but it is the Chinese translation that has brought the big numbers. On my December 2017 trip to China, I was signing books from the 43rd printing in Chinese. 

Why has the book sold so well in China?

Two main reasons. The first factor is a fortunate coincidence. When the Chinese translation was released in 2009, the ministry of health in China was addressing what they labeled “health reform” in China. The book found its way into the ministry of health. Leaders there quickly called a number of respected healthcare leaders to Beijing for a couple days of conversations about how the book’s lessons could be applied in the Chinese health system. It was coincidental that it provided the kind of information they were looking for at that time.

A provincial minister of health told me, “I read your book once. Then I read it again. And then I ordered 500 copies to give to each hospital in my province.” This kind of reaction may help explain why the book was recognized as the 2009 Social Science Book of the Year in China.

And the second factor is that the Chinese often look for whatever they consider the best of something. They mention frequently the ranking of U.S. hospitals in U.S. News and World Report. When they identify the best or one of the best they work to adapt the features of the product or organization to their culture, and hopefully even improve upon it. Mayo Clinic is a top-tier institution in the U.S., so naturally they would look to use its lessons in China.

So it’s possible that your book has made a major difference in how healthcare works in China, is that right? I don’t suppose you ever thought when you were writing it that it could make a difference to Chinese people in Chinese hospitals!

I never imagined a single Chinese reader when I was writing the book! In my mind I was writing to healthcare leaders in the U.S.

Happily, I have visited a number of hospitals in China where leaders have read the book carefully and provided a copy to every employee. Many healthcare leaders are doing their best to create a value-based hospital and patient-focused operation. A handful have done that work quite well. They stand out in contrast to many other public hospitals. Their transformation has become a “showcase,” with other hospital leaders coming there to see and learn about the transformation. It is gratifying.

The largest impediments the Chinese hospitals face in applying this in their hospitals are the cultural differences between China and the U.S. For instance, I am frequently asked about Mayo Clinic’s punishment of employees. Of course, punishment is not a topic in human resource management textbooks in the U.S. If an error occurs in a hospital in China, most leaders feel someone must be fired. Sometimes more than one person is terminated after a medical error has occurred. In the U.S., we know that most mistakes are not the fault of a specific person but rather the result of the system or process we have created. We fix the process and retain the employees.

Mayo Clinic’s success is based on teamwork that only thrives in a culture of mutual respect of everyone on the team. If the founders of an institution do a good job of creating a values-driven — rather than authoritarian — culture, it will endure for a long time. The Mayo family was guiding their organization for 70 years and created a culture that still exists today.

The Mayo Clinic is quite egalitarian. The Clinic’s success is found in the respect that leaders have for the talents and ideas of the employees — not only the doctors, but also nurses, technicians, and anyone who has an idea for something that might be better for patients. This is harder to do in the Chinese culture.

I do talk about this when I speak in China. It is important to have the culture — not just words and policies. Success is based to a large extent on organization culture.

I understand you have traveled to China a lot to talk about lessons from the Mayo Clinic.

Yes, I have made 22 trips to China between 2010 and the end of 2017. 

Do you go to different places around China, or do you keep going back to the same cities and universities?

I mostly visit different cities and hospitals every time — I’m told there are about 25 academic medical centers in Beijing alone. I’ve been to about five of them, so the market is not saturated yet. I’ve not been in the far west of China or in Tibet. 

The trips are all underwritten by the medical industry: equipment suppliers and pharmaceutical companies. On several of my trips the ministry of health is a co-sponsor. These sponsoring companies are committed to helping Chinese hospitals work more effectively. They see themselves as partners with hospitals and the ministry of health. 

I can see why the Chinese keep asking you to visit. But with that many visits, there must be something in it for you. You must enjoy it. What keeps you going back? 

My first career was in higher education. I like to teach, and it’s particularly nice to teach when you have a keen and intelligent audience. The eagerness with which people listen to the lectures that I give and then — the most fun part for me — ask penetrating questions during the Q&A period is very rewarding. I have the opportunity to think on my feet and respond to the real questions that they have.

And, to be straightforward, this has been a great way to supplement my retirement funds.

Would you write another book specifically aimed at Chinese healthcare managers? You must know an awful lot about their work by now. 

As you might guess, I have enjoyed my time in China greatly, as I keep going back. I have developed great affection for Chinese people. I have great appreciation of the culture and country. And their food.

However, in spite of the fact that I have been there for about 10 months of time over eight years, I don’t know the culture well enough to feel I am in any way an expert with THE answer for their needs. I don’t speak the language. Because I hear the words of my translator, I don’t understand the subtle nuances of cultural dynamics in committee meetings I attend. And also, I don’t fully comprehend the complex structures of the reporting relationships to the ministry of health in cities, provinces, and the national government. Yes, I see a lot, but to give advice on how to run hospitals in China one needs a lot more insight into how people, hospitals, and families work there. It is hard to assimilate all of that in two-week tours through China. 

But I do have one passion. One small change I speak to: hand washing. I refer to it as a clue of excellence that is missing in too many hospitals in China. I talk about hand washing before touching patients. Many hospitals — including academic centers in the large cities — don’t have soap or towels in restrooms. In a hospital where I was consulting, there was no soap to be found at the restroom handwashing sink in the cancer center where patients are immunosuppressed. Then in that same hospital I went to the cafeteria for dinner and asked the staff where I could find some hand soap to use before eating. After about 15 minutes, they returned with a small bottle of hand soap. In another hospital, a doctor said to me, “We don’t have much money to run the hospital. If we put soap in the rest rooms. . .” She didn’t finish the sentence because she saw where the sentence was headed. (And I do carry hand sanitizer in my pockets.)

Management Lessons from Mayo Clinic was first published 10 years ago now. The healthcare world and the business world are both evolving so rapidly — do you think that your book will continue to stay current?

I think so. The Mayo Clinic culture has been developed over 150 years and the management system has been in place for about 90 years. Those features of Mayo Clinic are the critical infrastructure of the organization and the focus of our book. New clinical technology and new government policies and programs will come along. Mayo Clinic has a long history of adapting to the external environment without sacrificing its values and vision or its management and culture. 

We wrote about the big picture of Mayo Clinic. Mayo Clinic has gone through some changes over the last decade since we wrote the book, but I think that what we say about Mayo Clinic is as true today as when we wrote it. In strong corporate cultures, if there is a leader who pushes change that is not compatible with the culture, then the culture will relax back toward the historic culture when that leader is gone. 

McGraw-Hill, our publisher, apparently believes the book will continue to speak to readers as our book appeared in paperback in mid-2017 as part of a series called Business Classics. The publisher must have looked at sales and concluded that the book in English had some enduring market.

What other languages have you been translated into?

The book has been published in a number of languages. I am working right now with a Japanese translation to come out this summer or autumn. In addition, there are translations in Russian, Korean, Arabic, Thai, and Portuguese.

Have you traveled to other places to talk about the book, other than China?

Yes, I’ve taken four trips to Russia. Russian healthcare is wrestling with some of the same kinds of issues as in China. I have also been to Malaysia, the Philippines, Indonesia, France, the Netherlands, Iceland, Belgium, Brazil. 

At a conference in Kazan, Russia, I listened as three physician leaders spoke about their efforts to apply our Mayo Clinic lessons to their hospitals. One of the gifts that come to writers are the tidbits of information showing that readers have been moved to action. These Russian doctors working in cities I’d never heard of are a precious gift that I hold even though I didn’t understand a word of their Russian lectures. Also, I cherish the knowledge that our book found its way into the automotive dealers in Russia where I was told that it had become “required reading.”

The travel has become one of the gifts that has come to me just because I ended up working at a famous institution. This has become my career in retirement. 

You have consulted for the ministry of health in China and other countries that have a very different healthcare system than that in the U.S. Isn’t it a little bit difficult to translate lessons from the private Mayo Clinic to the very different public system in China and other places? 

Yes, there are challenges. First, I should say that Traditional Chinese Medicine is an important segment of Chinese health services. For many patients it is where they first seek care. Sometimes this is the only care that poorer patients can afford. Many, if not most, academic medical centers have a department of Traditional Chinese Medicine. The culture surrounding this care has developed over 2,500 years. I don’t think that modern management has much to help these operations.

My work has been primarily in public teaching hospitals where over 95 percent of the 150 year-old western medicine is offered. There are increasing numbers of private hospitals in China. Largely, these new private hospitals are designed to serve expatriates living and working in China as well as the growing segment of Chinese with significant wealth. I’m also aware of an initiative for a nominally private investment group to acquire more public hospitals and transform them into private hospitals.

The public teaching hospitals are affiliated with university medical schools. These hospitals train residents and fellows. Teaching hospitals have been, up to this point, the focus of growth in healthcare services in modern China. These hospitals represent the beginning of the healthcare infrastructure over the past 20 years or so.

The status of these hospitals is based to a large degree on the tangible assets. When CEOs talk about their hospitals, they speak first about bed size. A five-thousand bed facility is the largest hospital I’ve visited. Most have about 2,500 beds. The second defining feature of the hospitals is technology. CEOs describe the equipment in radiology, cardiac care, and the clinical laboratory. The typical CEO does not talk much about patients other than to say the doctors there will see 100 to 150 patients a day.

If you were to go to virtually any of the academic centers in China in the early morning you would see a large room with people pressed together trying to get up to a window where appointments for that day are being made. Because people who get sick don’t have confidence in primary care doctors they want to come to the larger academic hospitals for the flu and colds as well as chest pain. These hospitals feel that they can’t really turn these people away.

I deeply admire the industry of the healthcare work force in China. “Work/life balance” is not a consideration — it is as if most of those employed have not yet reached a secure financial and social status that enables them to enjoy the luxury of leisure. A hospital CEO told me that he had not had a vacation day in over 25 years. He sometimes traveled out of his city to attend a meeting, but otherwise he was at the hospital every day.

My message in China is focus on patients. Yes, Mayo Clinic is private but it has the same components that public academic medical centers have: patients, doctors, nurses, budgets, cash-flow, technology. Mayo Clinic has over 60,000 employees and maintains a patient focus from almost every employee. Patient focus should ultimately address the issues of physician/patient ratios as well as dozens of other patient-centered opportunities in China’s hospitals.

What does not exist in China today is a healthcare system. China has built the top of the healthcare pyramid. While there are some secondary hospitals and primary caregivers, they have not earned the confidence of the public. The current healthcare reform in China focuses on creating professional primary care and secondary care systems. 

You said that traveling to talk about lessons from Mayo Clinic has become your career in retirement. Have you thought about moving into a more traditional type of retirement anytime soon? Are there other projects you would like to pursue? Maybe you want to write another book? Spend time with the grandchildren? Swim or hike? Sit still?

I certainly want to retire while I am still alert and oriented. But my health is good, my mind still seems to work, and I am enjoying the people that I travel with in China and Russia in particular. I’m privileged to see these countries while embedded in the culture in the presence of very smart locals rather than western tourists on a bus. I am thinking maybe one or two more years might be enough. But it’s so much fun that it’s a little hard to give up.

I don’t think I will write another book. There is a small possibility that I’ll collaborate on a book focused on employee training in China. But the Mayo Clinic book has been so successful that anything else I would do would be a failure in comparison.

I do have a woodworking hobby and have a nice workshop in my basement. I enjoy exercise and need to do more of it. Exercise has really been compromised by all of this travel.

I live near one set of grandchildren in Spokane, Washington, and have another set in Arlington, Virginia. Seeing my grandchildren and my daughters is an important part of my life.

I’d like to connect with some of my old friends and colleagues from the past. I have not done very much in that arena. Perhaps I’ll do a few leisurely drives around the country one day. 

Have you met any Adventists in China? Have you seen any of the Chinese women pastors preach? 

I am not an Adventist who has been an Adventist tourist — one who seeks churches wherever I might be in the U.S. or China, or Europe — on a Sabbath. But on my first trip to China I went with an internist from Mayo Clinic who worked for six years at Sir Run Run Shaw Hospital in Hangzhou, China. This hospital is affiliated with Loma Linda University Health. So I attended an Adventist Church in Hangzhou with him, and it was quite interesting. Of course, I didn’t understand any of the language, though one member did whisper a few English words in my ear. The pastor there was a man with a graduate degree from the seminary in the Philippines. The text was from Revelation, and I had always imagined a river like the Mississippi or Missouri turning red like blood — I had never imagined it as the Yangtze! How provincial I have been.

You began your career teaching English at Pacific Union College, right?

Actually, my first job was at Columbia Union College from 1965 through 1970. Then I went to Pacific Union College from 1970 to 1984. That was 19 years in higher education. In 1984 I went to Florida Hospital in Orlando and was there for three years as director of public relations and marketing communications. While there I attended night school to earn my MBA. In 1987 I went to Loma Linda University Medical Center to lead out in the establishment of the Loma Linda International Heart Institute, and was there until 1992 when I went to work in marketing at Mayo Clinic.

Where did you earn your degrees? 

I am an English major graduate of Union College in Nebraska, and then did a masters and PhD in English at the University at Nebraska. I focused on 18th century British literature. My MBA is from the Crummer School of Business at Rollins College in Winter Park, Florida.

So how did your English degrees and teaching English prepare you for your marketing job at the Mayo Clinic?

Clearly this is not a career path that a parent or a college academic advisor would ever outline for a college freshman! But it has worked extremely well for me. 

Marketing is based on listening to the marketplace, which requires lots of research. So, training in humanities research was very valuable to my work in market research. I have moderated a few hundred focus groups, listening to the voice of customers. One could look at the language used as just conversation, but I chose to look at it more as poetry. Like poems, the language of consumers has more content than the words they are literally saying. The best marketers look for underlying meaning in discourse. For instance, a patient might say: “You need an 800 number for the urology department.” But it’s not so much that they want a toll-free number; they want a number that will give them ready access. The issue is actually access. So, training in discourse analysis and literary analysis was very valuable to me.

Also, marketing can be viewed as social science research. When trying to understand social behaviors around healthcare services, the researcher must be careful about language that he/she uses. It is vital that researchers not lead respondents to certain answers. Here I found my knowledge of language structure to be extremely important. And my classroom experience had taught me by trial and error how to probe the mind of students by asking penetrating questions that hopefully evoke something from the student that they might not have yet considered or, even better, evoke something that I’ve not thought of before. The kind of close reading, language analysis, literary analysis, and provocative pedagogy at the core of the English major is very applicable to marketing. 

However, the core liberal arts education has also been very valuable. Somewhere in my biology courses I learned enough about human anatomy and physiology to understand the chair of neurologic surgery as he was describing in lay language the patients he wanted us to attract to the program. And I also needed to build on my knowledge of mathematics in order to understand and use statistics, which is a core competency required in marketing.

I’d like to add that when my staff and I put together a marketing plan and presented data, we needed to be persuasive. As consultants to the organization, we needed to do more than present numbers and facts to our clients. We needed to make recommendations. We were not neutral third parties. We were expected to do analysis and give committees our educated opinions. And then we needed to use our knowledge of rhetoric to fashion a persuasive oral and written report. 

The skills I had developed as an English major and teacher were very important in this part of my work. 

It was a lot of work to get a PhD in English literature, and I probably didn’t have to get that degree to be successful in marketing, but it worked out well for me!

What advice would you have for young Adventist graduates who are out there looking for a job in healthcare or marketing?

It starts before graduation. Get a solid education as an undergraduate. Specialize in graduate or professional education. I’m a strong advocate of the liberal arts educations that include an understanding of the ideas that have created the culture we live in today. This means history, theology, literature, foreign languages, mathematics, science studies at a level that you comprehend the scientific method of creating knowledge. This education can prepare you for many opportunities that will arise in your first job after graduation.

Healthcare marketing did not exist as a professional career when I graduated from Union College in 1964. It was possible for me to succeed because I’d acquired knowledge in the broad range of ideas taught as a liberal education.

And for those who aspire to leadership in healthcare, academics, business organizations, or religious organizations I would advise that you should train to become the clearest thinkers, most effective communicators, elegant problem solvers, and empathetic human beings. Learn how to think and read critically and how to write clearly, succinctly, and persuasively, and how to speak effectively to an educated professional audience. Hone those skills. Become an unsentimental editor of your writing and invite colleagues to critique your work. I have a practice of having colleagues read everything I write before sending it off to a publisher. I want my dearest friends to criticize me first.

Interestingly, I never hired anyone with an undergraduate degree in marketing to work in marketing at Mayo Clinic. I mostly looked for very high-achieving professionals — people who were intellectually and socially gifted with skills to earn the credibility of any physician leader at Mayo Clinic. Those who rose to the top of the candidates had strong liberal arts undergraduate degrees as well as an MBA or other social science master degree. This mix of considerations led me to employees from the humanities and social sciences: Spanish, art history, English, criminal justice, political science and master degrees in international relations, business administration, English, and healthcare administration.

What books are you reading right now?

I am reading two books. One is a curious and fun novel: A Man Called Ove, originally published in Swedish. I am also reading Bill Johnsson’s book: Where Are We Headed? Adventism After San AntonioHe writes so well and is so articulate. 

I read online daily about culture and national and international news: the New York Times, Washington Post, and local newspapers to keep in touch with what is going on in the world. The New York Times has the best coverage of China of any U.S. paper.

Kent Seltman retired from Mayo Clinic at the end of 2008. He relocated from Rochester, Minnesota to Spokane, Washington.

Photo courtesy of Kent Seltman.

Alita Byrd is interviews editor for Spectrum.

 

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